Enrollment through Health Insurance Exchanges Lagging, but Humming Along In Medicaid in Many States

Amid the attention focused on technology flaws of the nation’s new health insurance exchanges, a happier story has received less attention: the relative ease with which many Americans newly eligible for an expanded Medicaid program are now enrolling in coverage in many states. There’s a lesson in this story for all of us—that governments at many levels can, and often do, get things right. But sometimes it takes years of effort, policy changes, big dollar investments, and improved know-how to make all the processes work.

Consider these developments:

Express-lane enrollment: With technical assistance from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network, several states, including Oregon, have adopted accelerated processes for signing up Medicaid enrollees. Starting on September 26, Oregon sent letters to about 260,000 households in the state that it had determined were eligible for “fast track” Medicaid enrollment because they or their children were already enrolled in other programs for low-income people—the federal Supplemental Nutrition Assistance program (SNAP), or the state’s Children’s Health Insurance Program.

Thanks to a waiver Oregon received from the federal government, recipients merely had to fill out a short paper form and mail it back to the state’s health authority to sign up for the expanded Medicaid program. Already more than 70,000 have been enrolled in that program, the Oregon Health Plan, says George Washington University law professor and Medicaid expert Sara Rosenbaum—a number that exceeds the tally of state residents who so far have been able to enroll in private coverage through the state’s health insurance exchange.

Operational efficiencies: A number of states have overhauled their Medicaid enrollment processes with the aid of tens of millions of dollars in federal funds, along with million-dollar grants from the Robert Wood Johnson Foundation. With the help of the Foundation’s Maximizing Enrollment initiative, for example, Massachusetts adopted an all-electronic document management system that allows enrollment officials to answer any questions that applicants have immediately. New York also moved from a county-based to a centralized state enrollment system. Thanks to these and other changes, both states are estimated to have signed up tens of thousands of newly eligible Medicaid enrollees in just a few short weeks.

The Affordable Care Act required states to undertake many of these improvements regardless of whether they expanded their Medicaid programs, notes a report from the National Academy for State Health Policy (which provided technical support to the Maximizing Enrollment program). Under the law, states have been required to shed outdated, paper-based enrollment systems to create an Internet-based “enrollment superhighway.” Among other changes, they have had to create web portals for filing applications and obtaining benefit information, and to allow applications to be submitted online and by phone—even to the point of accepting a person’s verbal “signature” on an application through an audio recording that is added to an applicant’s case file.

Takeaways: As states have put these changes in place, they’ve learned valuable lessons, some of which could also have a bearing on their future plans for health insurance exchanges. In modernizing its enrollment process, for example, Utah state officials designed some of its new information technology tools, rather than outsourcing the tasks to private commercial vendors. The state has also put its staff in charge of reviewing all proposed information technology projects so it can reject any that don’t fit with “Utah’s vision and technology operations,” the NASHP report notes.

It’s unclear at this point whether a more hands-on governmental approach would have benefited the troubled federal health insurance exchange, which has been overseen by the Centers for Medicare and Medicaid Services, but primarily built by private commercial information technology vendors. Although the federal exchange is supposed to function as a portal through which people can also learn if they’re qualified for Medicaid, the federal website can’t yet reliably refer people over to the states to enroll. These and other aspects of exchange implementation are sure to be a focus of the post-mortems that will follow in the months ahead.

And one important lesson may be that with more investment of ample time, energy, money and information technology expertise—as a number of states made in their Medicaid programs—the exchange may have been executed with fewer hitches.